[Important prognostic significance of a sentinel-node biopsy in patients with malignant melanoma]. / Belangrijke prognostische betekenis van schildwachtklierbiopsie bij patiënten met maligne melanoom.

OBJECTIVE: To determine the prognostic significance of sentinel-node biopsy in patients with malignant melanoma (unlike the United States, a sentinel-node biopsy is still not routinely performed on melanoma patients in the Netherlands, as the outcomes of prospectively randomised clinical trials are being awaited). DESIGN: Retrospective. METHODS: Between 1996 and 2001 a sentinel-node biopsy and a re-excision of the scar of the diagnostic biopsy were performed on all melanoma patients who had a Breslow thickness > or = 1 mm or a Clark level > or = IV. At operation the sentinel node was identified with a gamma probe and patent blue. It was removed and sent for pathological investigation for the presence of melanoma cells. If the sentinel node was tumour positive, a dissection of the regional lymph-node basin was performed. Subsequently, these patients were put forward for the European Organisation for Research and Treatment of Cancer (EORTC) peginterferon alfa(2b) adjuvant treatment study. RESULTS: A sentinel-node biopsy was performed in 61 lymphnode basins in 57 patients (18 male and 39 female; median age: 45 years (range: 9-80)). The median Breslow thickness of the melanomas was 2.2 mm (range: 0.7-13 mm). In 10 of the 61 cases histological examination of the sentinel node demonstrated tumour cells. In 2 additional cases tumour cells were demonstrated only by immunohistochemical studies or complete dissection of the node. Eight regional lymph-node basins were dissected, two of which contained additional metastases. The median follow-up was 36 months (range: 1-68). During follow-up 12 of the 57 patients were found to have metastases, in 8 of these patients the sentinel-node biopsy contained tumour cells. The negative predictive value of a tumourless sentinel node with respect to the later occurrence of distant metastases was 92%. CONCLUSION: The patients with a tumour-positive sentinel node had a poorer prognosis with respect to distant metastases than patients with a tumour-negative node. This is the main reason for performing sentinel-node biopsy: to predict the prognosis of the disease. Therefore sentinel-node biopsy should be incorporated into the treatment of patients with malignant melanoma.

[Very slight chance of other metastases in axillary nodes of breast cancer patients with a small sentinel node metastasis without extranodal tumor growth]. / Zeer geringe kans op andere kliermetastasen in de oksel bij borstkankerpatiënten met een kleine schildwachtkliermetastase zonder extranodale tumorgroei.

OBJECTIVE: To determine in patients with mammary carcinoma and a sentinel node metastasis whether pathological parameters of the sentinel node metastasis and the primary tumour might have predictive value with respect to the presence of metastases in other axillary nodes. DESIGN: Prospective. METHOD: The study group consisted of the first 100 consecutive patients with a sentinel node metastasis, who subsequently underwent a complete axillary dissection. The patients with metastases in the non-sentinel nodes were compared to those without such metastases regarding the size of the largest sentinel node metastasis and the presence of extranodal tissue invasion near any such node, and size, and type of the primary tumour. RESULTS: The median size of the metastases in the sentinel lymph node in the two groups was 3 mm versus 13 mm respectively (p < 0.001) and the frequency of extranodal tissue invasion 3% versus 74% respectively (p < 0.001); the combination of these factors strongly predicted the presence of non-sentinel lymph node metastases in the axilla (94% area under the receiver operating characteristics curve). None of the 30 patients with a micrometastasis < or = 2.0 mm in the sentinel lymph node had metastases in the non-sentinel axillary lymph nodes. Metastases were present in the non-sentinel axillary lymph nodes in 29 of the 31 patients with extranodal tissue invasion near the sentinel node. CONCLUSION: In breast cancer patients with a sentinel lymph node metastasis < or = 2.0 mm and without extranodal tumour growth a complete axillary lymph node dissection might be unnecessary as the risk of additional metastases was very small.

[Less operations required due to perioperative frozen section examination of sentinel nodes in 275 breast cancer patients]. / Minder operaties vereist door peroperatief vriescoupeonderzoek van schildwachtklieren bij 275 patiënten met mammacarcinoom.

OBJECTIVE: To determine the reliability of a peroperative frozen section examinations of sentinel lymph nodes in mammary carcinoma. DESIGN: Retrospective. METHOD: In the Reinier de Graaf Hospital and Diagnostic Centre SSDZ Delft, the Netherlands, the results of frozen section from sentinel lymph node investigations of mammary carcinomas from 1997-2000 were compared with the final pathological results. If axillary dissection had been performed on these patients, the histopathological findings of the dissected lymph nodes were also studied. RESULTS: Frozen sections were made of 287 sentinel lymph nodes from 275 patients. A tumour was found in the sentinel lymph nodes of 64 patients and these patients immediately underwent a complete axillary lymph node dissection. For 31 of these patients a tumour was also found in the other lymph nodes. In 29 of these 31 patients, histological examination had shown extranodal extension. The frozen sections from the sentinel nodes of the remaining 211 patients were considered negative. However, in 13 of these patients, the paraffin sections of the sentinel node nevertheless showed a tumour and the remaining axillary lymph nodes were removed in a second operation. In the last 89 patients studied, the sentinel lymph nodes were cut at four levels and stained immunohistochemically at one level for cytokeratins. Accordingly micrometastases were found in the sentinel lymph nodes of 4 of the 13 patients with (false-)negative frozen sections. False-positive results did not occur. CONCLUSION: The major advantage of the sentinel node method in breast cancer is that for women without metastasis present in the sentinel node, axillary dissection is avoided. By means of a peroperative examination of frozen sections, 83% of the patients with a metastasis in the sentinel lymph node (or about one quarter of all patients) were spared from having a second operation for axillary dissection at a later stage.

Rupture of a hepatic artery aneurysm caused by Wegener's granulomatosis.

Among vasculitis syndromes Wegener's granulomatosis (WG) is characterized by involvement of the upper and lower airways and kidneys. The associated vasculitis involves small and medium sized arteries and veins. Aneurysm formation and a segmental pattern of involvement of larger arteries is not typically seen in WG--a presentation more in keeping with polyarteritis nodosa. We report on a patient hospitalized with classical manifestations of WG who died suddenly of hypovolemic shock caused by intraperitoneal hemorrhage resulting from rupture of a hepatic artery aneurysm. The aneurysm was caused by involvement of the hepatic artery in the disease process. To our knowledge aneurysmatic dilatation of the hepatic artery due to WG has not been previously described. This case illustrates an unusual disease course in WG and the overlap which exists in classical vasculitis syndromes.

Analysis of lymphoid and dendritic cells in human lymph node, tonsil and spleen. A study using monoclonal and heterologous antibodies.

The distribution of lymphoid and dendritic cells in human reactive lymph nodes, tonsils and spleens was examined by means of an indirect immunoperoxidase technique, using a panel of monoclonal and heterologous antibodies. The antibodies used were directed against antigens present on T cell subsets (Leu1, leu2a, Leu3a, TA1, OKT6), various types of B cells (BA1, BA2, HLA-DR, CR1) and cells of the mononuclear phagocyte system (alpha HM1, TA1, CR1, OKM1, NA 1/34). In the lymph node and tonsil Leu3a-positive cells (T-helper/inducer phenotype) and Leu2a-positive cells (T-suppressor/cytotoxic phenotype) are found in the thymus-dependent or T-cell area; in the spleen Leu3a-positive cells are found mostly in the periarteriolar lymphocyte sheath (PALS), while Leu2a-positive T-suppressor/cytotoxic cells are almost completely restricted to the cords of Billroth in the red pulp. The cells in the mantle zone of germinal centres and in the primary follicles in lymph nodes, tonsils and spleens have B-cell properties (BA1-, HLA-DR-, and CR1-positive). The cells in the germinal centres show a similar staining pattern (HLA-DR-, and partly CR1-positive). Follicles and T-cell-dependent areas have specific dendritic cells, each with a specific staining pattern: the dendritic reticulum cell (DRC) of the follicle stain with CR1, HLA-DR, BA2 and alpha HM1; the interdigitating cell of the T-cell areas in the lymph node, tonsil and spleen stain with HLA-DR and BA1. Moreover, large dendritic OKT6-positive cells are found in the T-cell areas of some of the peripheral lymph nodes, and are probably Langerhans cells. It is concluded that human lymph nodes and tonsils have an identical compartimentalisation, clearly differing from the spleen in cellular organization.

The prognostic value of membrane markers and morphometric characteristics of lymphoid cells in blood and lymph nodes from patients with mycosis fungoides.

For 26 patients with mycosis fungoides (MF), the type and extent of the skin lesions, the percentage of cerebriform mononuclear cells (CMC), and T and B lymphocytes in the peripheral blood and lymph nodes were correlated with MF involvement of regional lymph nodes, the clinical course, and response to therapy. Skin tumors and an involvement of more than 25% of the skin correlated well with lymph node involvement. Normal percentages (2--18%) of CMC in the peripheral blood were found for MF patients without lymph node involvement when compared with those found for patients with benign erythroderma and healthy donors. Elevated circulating CMC percentages (greater than 20%) were observed in 9 of 11 MF patients with lymph node involvement. In the lymph node cell suspensions from nine of ten MF patients with lymph node involvement, increased CMC values were found (greater than 15%), whereas two of three MF patients without lymph node involvement showed percentages comparable (4% and 7%, respectively) with those of the control lymph nodes. In the peripheral blood of patients with MF, decreased percentages of T cells (less than or equal to 55%) were found predominantly for patients with lymph node involvement, whereas normal percentages were noted for most of the patients without lymph node involvement. No consistent differences in the percentage of T and B cells in the lymph node cell suspensions were found between MF patients with and without lymph node involvement. Patients with lymph node involvement showed in general a partial response to therapy with an unfavorable clinical course in contrast to patients without lymph node involvement. Increased percentages of CMC (greater than 20%) and decreased percentages of T cells (less than or equal to 55%) in the peripheral blood, the presence of skin tumors, and involvement of more than 25% of the skin are prognostically unfavorable signs for patients with mycosis fungoides.

Primary lymphoblastic non-Hodgkin's lymphoma of the skin.

The clinical, histological, and ultrastructural features of a patient with a primary lymphoblastic non-Hodgkin's lymphoma of the skin are described. Four months after the onset of the disease the patient died with extracutaneous involvement of lymph nodes, spleen, liver, kidneys and lungs. The rapidly fatal outcome without the development of leukaemia or involvement of the bone marrow and the mediastinum is uncommon.

Morphological aspects of T cell subpopulations in human blood: characterization of the cerebriform mononuclear cells in healthy individuals.

Cerebriform mononuclear cells (CMC) constitute a morphologically distinct subpopulation of T cells in healthy individuals. They are characterized ultrastructurally by a highly indented nucleus, a high nucleus-to-cytoplasm ratio, condensed chromatin along the nuclear membrane and a scanty cytoplasm. In order to characterize the peripheral blood CMC by enzyme-histochemistry and membrane characteristics, lymphocyte fractions enriched for T cells, T mu cells, T gamma cells and T cells without Fc mu and Fc gamma receptors (T0 cell fraction), or depleted of T cells, were investigated for the presence of alpha-naphthylacetate esterase and acid phosphatase at light and electron microscopic levels. CMC were found exclusively in the T mu-enriched and T0 cell fraction, indicating that these cells have either an Fc mu receptor or no Fc receptor at all. Except for their nuclear indentation, both the CMC in the T mu-enriched fractions and the CMC in the T0 fractions ultrastructurally resembled the characteristic cell in the T mu fraction (TM-type cell), but differed from the characteristic cell in the T gamma fraction (TG-type cell). Moreover, like the TM-type cells all CMC showed paranuclear dots of alpha-naphthylacetate esterase and acid phosphatase activity in their cytoplasm. From these observations it was concluded that CMC without Fc mu receptors were either stimulated T mu cells or precursor T mu cells. Thus CMC in healthy individuals constitute a distinct subpopulation of T cells not only morphologically but also histochemically and immunologically.

The relevance of morphometry in the differential diagnosis of cutaneous T cell lymphomas.

Morphometric analysis of lymphoid cells in the skin was used to differentiate between cutaneous T cell lymphomas (CTCL), i.e. mycosis fungoides (MF) and Sézary syndrome (SS), and chronic benign skin diseases. In electronmicrographs of the skin lesions from twenty patients with CTCL (group I), fourteen patients with chronic benign skin diseases (group II) and twenty-nine patients suspected of CTCL (group III), the degree of nuclear indentation of lymphoid cells, expressed as the nuclear contour index (NCI), was measured. Analysis of the NCI histograms of the infiltrating cells of group I and group II permitted us to derive classification criteria for allocating all patients correctly with a high probability (greater than or equal to 95%) in the appropriate group. Only one case was classified with a low probability (71%). The classification criteria are based on the presence of cerebriform mononuclear cells (CMC) with highly indented nuclei (NCI greater than or equal to 11.5) and the frequency distribution of CMC in the skin infiltrates expressed as the 25th and the 70th percentiles of the NCI histograms (P25 + P70). When these criteria were tested on twenty-nine patients suspected of CTCL, twenty cases were classified as malignant, nine as benign. During the follow-up period, out of the twenty patients classified as malignant, seventeen patients appeared to have or develop MF, whereas two patients had lymphomatoid papulosis and one patient is still suspected of MF. Of the nine patients classified as benign, eight patients were proven to have benign skin diseases whereas one developed MF in the follow-up period of up to 4 years. The classification results based on morphometry proved to be more sensitive than those based on DNA cytophotometry. It is concluded that morphometric analysis of lymphoid cells in the skin is of diagnostic relevance in the differential diagnosis of CTCL.

Early diagnosis of mycosis fungoides and Sézary's syndrome by morphometric analysis of lymphoid cells in the skin.

Mycosis fungoides (MF) and Sézary's syndrome (SS) are cutaneous T-cell lymphomas characterized ultrastructurally by the presence of lymphoid cells with deep and narrow nuclear indentations (cerebriform mononuclear cells or CMC). Early diagnosis of MF and SS is difficult because in their early stages they often resemble various forms of chronic, benign skin lesions. By measuring the frequency distribution of a nuclear shape parameter (nuclear contour index or NCI) of lymphoid cells in skin infiltrates using computer assisted planimetry, we tried to classify suspect cases into the malignant and benign groups. From 12 patients with MF or SS (malignant group) and 11 patients with chronic, benign skin lesions (benign group) the frequency distribution of the NCI of the lymphoid cell population was measured. Nonlinear discriminant analysis selected the 70th and 25th percentile of the NCI distribution of the lymphoid cells in the skin infiltrates as parameters by which these patients could be classified correctly into the malignant or benign groups with a probability of over 95%. The predictive value of these parameters was tested on ten patients suspected of having cutaneous T-cell lymphomas. Three cases were classified as benign and 7 as malignant. In a three-year follow up cutaneous T-cell lymphomas did not develop in any of the 3 cases classified as benign, MF developed in 5 of 7 cases classified as malignant, 1 patient has lymphomatoid papulosis and 1 patient is still suspect for MF. These results are compared with those of DNA cytophotometry performed on skin imprint preparations. It is concluded that morphometry of lymphoid cells in skin lesions of patients suspect for MF and SS can make an important contribution to an early diagnosis of MF or SS.

Diagnostic morphometry of isolated lymph node cells from patients with mycosis fungoides and Sézary's syndrome.

Mycosis fungoides (MF) and Sézary's syndrome are cutaneous T cell lymphomas, characterized by the presence of lymphoid cells with deeply indented nuclei (CMC) in the infiltrate. In order to find objective criteria for the diagnosis of early MF involvement of lymph nodes from patients with MF, we performed morphometric analysis of lymphoid cells in lymph node cell suspensions measuring the degree of nuclear indentation as expressed by the nuclear contour index (NCI). Statistical discriminant analysis was used to analyze the differences in the NCI histograms between lymph nodes without and with MF involvement and to select the most discriminating parameters for diagnostic classification. Using a training set of 6 lymph nodes from patients with unrelated diseases and 8 lymph nodes from patients involved by cutaneous T cell lymphomas, the mean and standard deviation of the NCI histograms were selected as the most discriminating parameters. All lymph nodes from the training set were assigned to the correct diagnostic classification group with a probability over 90%. The predictive value of the morphometric classification was tested on a set of 12 enlarged lymph nodes from patients with MF. The histological diagnosis was used as a reference. In 10 cases the morphometric classification was identical to the histological classification, whereas in two cases (1 classified as positive, 1 as negative) a disagreement was found. It is concluded that morphometry of lymphoid cells can contribute substantially to the diagnosis of early MF involvement in lymph nodes.

Cerebriform (Sézary like) mononuclear cells in healthy individuals: a morphologically distinct population of T cells. Relationship with mycosis fungoides and Sézary's syndrome.

The ultrastructural and surface marker characteristics of lymphocytes in human cord blood and peripheral blood of healthy donors were studied with respect to the presence of cerebriform mononuclear cells similar to those occurring in the dermal infiltrate of patients with mycosis fungoides (mycosis cells), and the skin infiltrate and peripheral blood of patients with Sézary's syndrome (Sézary cells). Cerebriform monuclear (Sézary-like) cells are characterized by a high nucleus-cytoplasm ratio, deep and narrow nuclear identations, condensed chromatin at the nuclear membrane and cytoplasm poor in organelles. Of the lymphoid cells in human cord blood and peripheral blood of healthy donors 6.7 and 8.7% respectively proved to be cerebriform mononuclear cells. Since these cells invariably form E-rosettes they are part of the T-cell population in healthy individuals. The finding of similar cells in the skin infiltrate of patch test areas of patients allergic to rubber, formalin and peruvian balsam--an expression of cellular immunity mediated by T-cells--suggests that these cells are reactive T cells. Not all (up to 85%) of the cerebriform mononuclear cells in patients with mycosis fungoides and Sézary's syndrome have T-cell membrane characteristics as shown by E-rosette formation. This suggests the presence of two populations of cerebriform mononuclear cells in mycosis fungoides and Sézary's syndrome. The relationship of cerebriform T cells as seen in healthy individuals with cerebriform or atypical mononuclear cells occurring in the Sézary syndrome and mycosis fungoides is discussed.

Biochemical and electron microscopical evidence for the presence of oncorna viruses in spleen tissue from two patients with haematological malignancies.

In extracts of spleen tissue from two patients with haemotological malignancies an RNA dependent DNA polymerase was found in particles with a density of 1.16, that is at the density of oncorna viruses. After treatment with noniomic detergents the enzyme activity was found in particles with a density of 1.23-1.24, similar to the density of oncorna viral cores. A simultaneous detection test with this core fraction material for 70 S RNA and RNA dependent DNA polymerase was positive for both patients. Electron microscopical inspection of the material with a density of 1.16 revealed immature C-type virus like particles, various stages of maturing particles and a number of particles resembling mature C-type oncorna viruses. In two normal spleens from patients with carcinoma of the colon and oesophagus respectively and in three spleens from patients with no history of malignancy no RNA dependent DNA polymerase was found. Material from one normal spleen was examined in the electron microscope and no virus-like particles were seen.